It's the antibiotics
Ignore the Chief Medical Officer’s fearmongering: antibiotic resistance can be tackled with new antibiotics.
The UK’s chief medical officer (CMO), Professor Dame Sally Davies, made a splash in the media this week with her warning that antibiotic resistance is the new climate change. There is a ‘catastrophic threat’ of ‘untreatable’ diseases, she said, which promise to return us to a ‘nineteenth century’ state of affairs. The CMO has form: she warned the House of Commons health select committee about the same problem in similarly stringent terms back in January – a case not so much of apocalypse now, as apocalypse again.
As with all such stories, reading the actual CMO’s report leavens some of the hysterical excesses of the press, which were stoked up by the CMO’s excitable media appearances. Setting out the epidemiology of infectious diseases in the UK, the report highlights that while some drug-resistant infections, such as the well-known Clostridium difficile (C diff) and MRSA, are becoming less widespread, there is an increasing occurence of harder to treat multi-drug resistant bacterial infections, which, although still only in the hundreds of cases per year, are on the rise. The report states that only five antibiotics to fight such infections are currently in phase II or III trials, so the cupboard seems worryingly bare of new, necessary drugs.
So if we’re running short on drugs, how can we make more? A sensible article in the British Medical Journal from 2010 clearly set out the challenges facing the development of new antibiotics. Firstly, there are many regulatory hurdles that make running clinical trials in this area difficult. More importantly, there is a major financial disincentive for drug companies to develop antibiotics. Currently, drugs which are profitable are those for chronic conditions that are prescribed lifelong: painkillers for arthritis, diabetes drugs, and the like. A drug that you take once to cure you is unprofitable; doubly so if it is likely to be husbanded to prevent resistance developing until the patent runs out. A change in government payments to incentivise new antibiotics, like that which already applies to so-called ‘orphan’ drugs for rare diseases, would be an easy and rational step towards producing more drugs that meet our needs.
While there is some discussion as to whether the low-hanging fruit of easily produced effective drugs have already been picked, if you’re not even trying to harvest from the tree, you’re not going to find any fruit. As the BMJ article states, only 1.6 per cent of all drugs in development by big pharmaceutical companies are antibiotics.
These are fairly boring and technical changes to the drug development and reimbursement processes that could have a big impact, and both are within the government’s gift. To be fair, the report does recognise these problems, but of 150 pages, only about three look at the barriers to new antibiotics and prospective research strategies. Out of 17 policy recommendations, covering everything from improved diagnostics and stewardship of existing antibiotics to the inescapable public-health programme to ‘improve people’s knowledge and behaviour’, a grand total of zero refer to the production of new drugs.
So why does the CMO prefer to scaremonger rather than take steps to solve the problem at its root? Partly, the report reflects the kneejerk Malthusianism that is prevalent today, and not just in relation to antibiotics. Everything from food to energy is now seen as being invariably limited, which means it has to be tightly regulated, apparently, in order to prevent overconsumption. To this fragile mindset, rational scientific inquiry and government intervention into the market to solve a problem is seen as a foolhardy task. The only solution, it seems, is strictly to limit the use of antibiotics. But practitioners in medicine, of all areas, should be sceptical of such low horizons. The continual innovation that incrementally pushes the boundaries of what is possible today, and the explosive creativity of the postwar medicines boom, so vividly illustrated in James Le Fanu’s The Rise and Fall of Modern Medicine, give the lie to these socially imposed limits.
But the absence of any drive to manufacture new antibiotics is also down to the free-floating anxiety that afflicts those in authority. Confronted by a practical problem – in this case, a possible shortage of effective antibiotics – the medical establishment seems only able to deal in worst-case scenarios. The CMO’s choice of comparison – climate change – is deliberate and revealing: an open-ended threat, far off in the future, that requires exceptional measures here and now. This kind of ‘unknown unknown’ is much easier to deal with than the grubby reality of the fallout from the Mid-Staffordshire Foundation Trust, where the inept running of hospitals may have led to 1,200 deaths, or the latest ‘re-disorganisation’ of the health service. For those at the top, fearmongering functions as a cover for discombobulation, to put a medical name to an existential problem.
As for the rest of us, the best response to excitable reports of rampant antibiotics-resistant infections would be to take chill pill.
Robin Walsh is a trainee doctor at the University of Sheffield.
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